1083762819 NPI number — STEFAN MONTGOMERY MD FAMILY & SPORTS MEDICINE, PA

Table of content: (NPI 1083762819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083762819 NPI number — STEFAN MONTGOMERY MD FAMILY & SPORTS MEDICINE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEFAN MONTGOMERY MD FAMILY & SPORTS MEDICINE, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083762819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1785
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGEBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29116-1785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-395-4499
Provider Business Mailing Address Fax Number:
803-395-4480

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2850 PELHAM CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29118-1400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-531-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONTGOMERY
Authorized Official First Name:
STEFAN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
803-531-8500

Provider Taxonomy Codes

  • Taxonomy code: 207QS0010X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000199439 . This is a "UNISON" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 000000199441 . This is a "UNISON" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: DE2500 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20059042 . This is a "SELECT HEALTH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 7455015 . This is a "CIGNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 272779 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7259579 . This is a "AETNA" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP4594 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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